Problem solving process based computing

ABSTRACT

A computer implemented problem solving system utilizing an information storage infrastructure and a flexible development environment for data storage, includes a stored, user modifiable program including a problem solving rule set relevant to a problem to be solved, a stored, user modifiable set of vocabularies related to a problem to be solved, at least one stored, user modifiable knowledge set relevant to a problem to be solved, and stored, user modifiable individual user preferences relevant to a problem to be solved. A computer implemented problem solving method utilizing an information storage infrastructure and a flexible development environment for data storage, includes generating screen displays on a display screen, and entering a problem identified by an initial assessment to the computer at a designated place in one of the screen displays. The method further includes selecting from at least one of the screen displays at least one item from at least one of: a stored, user modifiable set of vocabularies related to a problem to be solved, at least one stored, user modifiable knowledge set relevant to a problem to be solved, and stored, user modifiable individual user preferences relevant to a problem to be solved and entering the at least one item to the computer at a designated place in one of the screen displays.

This application claims the benefit of U.S. Provisional Application No.60/681,937 filed on May 17, 2005.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to a novel and improved problemsolving process (PSP), and particularly, a problem solving process inrelation to the medical field/domain

2. Description of the Related Art

Before disclosing the details of the problem solving process in relationto the medical field/domain, the applicant will synopsize the currentstate of computerized design in this area following 36 years ofcontinued efforts. Medicine is a highly complex field/domain that takesyears of training to become proficient in. It has the challenges offollowing data over decades, resolving acute and chronic conditions,documentation requirements with medical legal implications, and truelife and death situations. It is also a field where adoption ofcomputerized medical record systems has had extremely limited successdespite decades of investment, research, and strong external pressuresto computerize. Applicant contents that the entire field of medicine canbe reduced to a PSP or Problem Solving Process Computing (PSPComputing). PSP Computing distills the entire field of medicine to the“Problem Solving Process,” with all its necessary outputs or charting(documentation, prescriptions, orders, instructions, alerts, schedulingtasks, etc.) automatically produced as a by product of solving theproblems.

Applicant contends that the same Problem Solving Process can do the samein any field/domain that solves problems over time. This applicationwill primarily show this concept related to medicine, but will showscreenshots of other fields/domains that could be converted using thesame principles. Specifically, Applicant further claims that the exactsame Process can be applied to any field/domain (i.e. law, consultancy,computer programming, detective work, etc.) that solve problems overtime.

Before proceeding, the Applicant will discuss the difference betweenwork of practicing ones profession (problem solving) and the work ofdocumenting what occurred. Let us take as an example, a medical doctor(M.D.), physical therapist, or chiropractor performing a therapeuticmaneuver or dispensing a prescription to relieve a patient's back pain.Solving the problem is the “real-” work or goal of the encounter. Theclient wants the professional/doctor to solve the problem. Solving theproblem is what the professional has been trained to do. To mostprofessionals, problem solving work can be exhilarating, as they areusing their skills to accomplish a goal that makes them matter. Ifsolving the problem provides a complete cure of the problem, never torecur, the quality of the documentation in that simple example wouldpotentially be immaterial. Yet, in the medical field/domain, andmajority of others, it is the documentation, or the “work-” work thatbecomes the major requirement of the visit for payment and medical legalreasons.

Since this documentation/paperwork has both financial and legalramifications, software solutions have focused on duplicating thedocumentation requirements of medicine and other fields/domains, as theyconvert from the “paper world.” Designed around the outputs of thefields/domains they computerize, they are fundamentally flawed. Thisform/output based design leads to greater documentation requirements,like proper formatting requirements. These requirements lead to steeplearning curves and often more time documenting the encounter than timespent solving the problem. Computerized documentation requirements areoften more cumbersome and time consuming than its “paper world”counterpart. This form/output based design increases the workload of theprofessional, and even with the many generic advantages of computers(like data analysis or location independence), will never lead to theefficiencies of a Problem Solving Process design.

Before disclosing the details of the Problem Solving Process in relationto the medical field/domain, Applicant will synopsize the current stateof computerized design in this area following 36 years of continuedefforts. For example, in the medical domain, designing around thecharting process in Electronic Health Records (EHRs) or ElectronicMedical Records (EMRs) has been the standard design since 1969. Thisapproach has not had significant market penetration (currently reportedat 5 to 13 percent of M.D.'s use EMRs despite billions of dollars ininvestments and extraordinary public, administrative, and payor pressureto computerize).

The “Paper World”

The original thrust to computerize the medical record came from LarryWeed's seminal work in 1969. See L. L. Weed, Medical Records That Guideand Teach, N. Eng. J. Med., 593-600 278:11 (1968). He correctlyconcluded that the medical record had no standard format. It wasentirely at the whim of the individual practitioner regarding how muchdetail of the patient's complaints was put in the note. Prior to Weed,many practitioners had the complete history and physical records oftheir entire patient population on 5″×6″ index cards. These index cardmedical records had an extremely filtered set of details about thepatients' medical history. For prescriptions, the notes would often justhave the date and the drug, such as “4/01/1960—Penicillin I.M.,” with noindication of why the medication was given and what was the outcome ofthe intervention. Even in hospitalized patient records, the details ofmany problems were often meshed together in a single paragraph in asloppy manner. If a problem such as chest pain led to anelectrocardiogram (EKG) and a cardiology consultation, these “plans”were often not even linked to their source. Instead, they were simplylisted at the end of the note, or they were not listed in the note atall and just ordered on an order sheet in a separate part of the chart.The outcome of these plans was generally not individually noted in thefollow up. This entire record keeping process was very informal. It wasnot formalized as it was not a necessity or an advantage in the “paperworld” to chart it.

Computerization of the Medical Note

Dr. Weed proposed a new format for the medical note around twofundamental concepts. These were the Problem Oriented Medical Record(P.O.M.R.) and the Subjective, Objective, Assessment, and Plan(S.O.A.P.) chart note. The P.O.M.R. elevated each of the patient'sproblems to the highest level in the chart and then organized theS.O.A.P. format as the means of reporting how the problem was doing inthe follow-up visits. He also championed the use of flow sheets tofollow the data that accumulated around the problems for simpleranalysis.

The result of Weed's efforts led to “Problem Lists” as an organizationaltool and the S.O.A.P. note as the formatted note structure underneatheach problem. However, the patient could still be cared for withoutformally using any component of the Weed method. The M.D. might not beas organized or the documentation might seem less complete, but thepatient could be cured nonetheless. The amount and form of documentationwas still entirely up to the individual, despite Weed's New EnglandJournal of Medicine article and the adoption of the P.O.M.R./S.O.A.P.method at some medical schools. Many M.D.s continued to write notes intheir own format, and others used the P.O.M.R./S.O.A.P. styleintermittently, and many were exclusively P.O.M.R./S.O.A.P. Even at thepeak of its popularity, the P.O.M.R./S.O.A.P. format never reached evena 50 percent level of adoption in the medical record. See Letter of K.C. Meyers & H. J. Miller to Academy of Medicine, The Importance ofCleaning up S.O.A.P., 72:9 933-4 (1997). See also Letter of A. S. Rubinto Academy of Medicine, Another Way to Enhance S.O.A.P.'s Usefulness,73:445 (1998).

Despite this, when EMRs began to be developed post 1969, this was theonly documentation standard in the medical field/domain that wasavailable. A “standard” with less than a 50 percent adoption rate isfated to have issues, and such it has been for the Weed design. As timewent on, the adoption of P.O.M.R./S.O.A.P. EMRs was underdeveloped.Adjustments were made with some EMRs still having a Problem List, butabandoned the requirement of using it for charting. Follow-up notesbecame an unstructured blank sheet of paper. Other EMRs completelyabandoned a problem focus, but enhanced the blank sheet of paper withshortcut key strokes or templates. These EMRs are often described as“Encounter Based” mimicking the paper world format of not requiring anassociation between the plans of treatment with the problems they wereordered for. In spite of it's free form, the Encounter Based approachwas more cumbersome than the paper record, as most physicians were notgood typists and it interfered with the face to face contact that couldbe made with the Patient chart.

A comprehensive review of the designs of EMRs in the last 36 years canbe classified into 3 views: (1) source-oriented (organizing the recordinto sections based on source of data, such as, x-ray, labs, notes), (2)time-oriented (organizing data chronologically), and (3)concept-oriented (the most famous example being the Weed P.O.M.R. orS.O.A.P. construct). An additional view is called the “Knowledge-based,Cconcept-oriented” view. This view was an attempt to decrease theinformation overload of current EMRs. It attempted to filter resultsbased on predefined views, such as “show all pulmonary tests for CHF.”The present invention is a new approach to EMRs/EHRs called “ProblemSolving Process Computing.” It is not a view, or a format, it is aprocess with major advantages over all of these concepts.

The Trouble with S.O.A.P.

The Weed design had a serious design defect, that was especially evidentas one tried to computerize the paper record. This fundamental flaw wasfocusing first on “S” or “subjective” and looking at the “O” or“objective” second. Thus, the process is designed around the conceptthat the first thing you chart on a follow up visit is the “S”—how thepatient feels about the state of the problem and any new related verbalinformation regarding the condition. Then, “S” is followed by the “O”which represents objective or measurable elements. This was defined byWeed as “Test Results and Physical Findings.” The “A” is for thedoctor's “assessment,” and the “P” is for the “plans.”

Working off of this standard was a major obstacle to designing aneffective EMR. That is because it the S.O.A.P. method puts the “S” infront of the “O.” This did not match the actual behavior of thephysicians, making it an artificial construct. There was a disconnectbetween what was documented and the actual order of what was done.Worse, the subjective section is substantially changed by the “P” planresults. That is, the specific questions that are asked in the verbalexchange (subjective) part of the visit, is substantially altered by theplan results. This combination of asynchrony and the effect the planresults have on the subsequent questions, are the fatal flaw of theS.O.A.P. note when it comes to computerization.

In contrast to the S.O.A.P. methodology, practitioners first looked atthe “objective” section that represented plan results, prior to askingany (subjective) questions. This objective analysis was routinely doneby the practitioner before walking into a patients' room in a hospitalor office. See K. C. Meyers et al., The Follow up note: Format andRequirements, Specifications for the Computerized Medical Record, AMIAProceedings: Orlando, Fla. (1997). Even doctor-to-patient phone callswould be preceded by a brief chart review before telephoning thepatient. This is because plan results always effect what questions thatare asked in the “S” of the S.O.A.P. note. For example, if a patientcomplained of a headache and an MRI of the brain did not show a braintumor, then the clinician would accept that the patient did not have abrain tumor based on the MRI. The clinician would not ask questionsrelated to the possibility of brain tumor in the “S” section. Anotherexample is a patient with a problem of abdominal pain. If the patienthad a Computer Tomography Scan (CT scan, or CAT Scan) that showedDiverticulitis, the M.D. would emphasize questions in the “S” sectionrelated to peanuts, seeds, popcorn and other related items that couldcause a flare of this illness.

The Institute of Medicine

The Institute of Medicine's (IOM) 1991 seminal work entitled TheComputer-Based Patient Record: An Essential Technology for Health Caredeclared the need to computerize the medical record for healthcare. SeeR. S. Dick, E. B. Steen, The Computer-Based Patient Record: An EssentialTechnology for Health Care, Institute of Medicine Committee on Improvingthe Patient Record (1991). The goal was to computerize the medicalrecord within 10 years. The IOM spun off the Computerized Patient RecordInstitute (CPRI) and the Nicholas Davies Award to pursue this goal. TheCPRI promoted standards and adoption of EMRs, including a standard thatlisted 154 requirements of a satisfactory EMR. Eventually, the CPRIproduced a document stating that if the specific 154 requirements of anEMR were accomplished, it would be successful. In 1999, after over 100million dollars invested by HBOC, the Smart Medical Record was pulledfrom the market, having completed 140 of the CPRI 154 requirements,partially done with 10 others, and only had 4 requirements notaddressed. This certainly brings up the issue of perceived requirementsversus the “real” requirements. It is the Applicant's contention thatall written requirements for EMRs, such as those proposed by theInstitute of Medicine focus on the chart structure, and not the realwork of the medical encounter.

Managed Care

During the 1990s, EMRs were heavily promoted by managed care companieswhich were transforming healthcare in their own right. This led tomassive investment of venture capital into EMRs due to manage care'sdesire to measure the care delivered. This also led to additional“reasons” why the EMR was essential. Data measurement was needed if onewas to apply more strict business principles to medicine. Goals includedthe elimination of the cost of paper records, legibility, HEDIS (HealthPlan Employer Data and Information Set) scores (essentially healthcarereport cards on the providers). Even these compelling business mandatesdid not prove compelling enough to overcome the basic usability problemsof the chart-based EMR. Some of these same arguments are beingproclaimed today by the Government and the Institute of Medicine as thereason EMRs should be adopted now.

The Internet

With the Internet emerging, some of these companies leveraged theirstock valuations to temporarily reap billions of dollars of paper wealthon the prediction that the portability of the Internet was the essentialtechnological development that would make EMRs successful. The Internetdid not lead to adoption and these companies had a reversal of fortune.Application Service Providers (ASPs) were also promoted as the solution.The theory was that the cost of the application would be less if managedcentrally over a DSL or T1 line, and that would convince M.D.s tochange; it was not the solution. The market for EMRs temporarily crashedwith the extraordinary amount of money lost in these ventures and thebursting of the internet bubble.

Electronic Health Record (EHR)

In 2000, the IOM released its next EMR report. See Linda T. Kohn et al.,To Err is Human—Building a Safer Health System, Committee on Quality ofHealth Care in America, Institute of Medicine (2000). Specifically, thisreport claimed that nearly 100,000 deaths per year could be prevented bycomputerized information systems. They contended that these errors couldbe reduced by using information technology. The report was followed byan attempt to improve the marketability of the EMR by changing the nameto EHR, or Electronic Health Record. Just as EMR had replaced theComputerized Patient Record (CPR) in the mid 1990s, it was hoped achange in name and slight change in focus would improve themarketability of these products.

The Government

The government became more directly involved due to 9/11 and the needfor an EHR to be in place in the event of a terrorist attack utilizingbiological agents. In addition to these national security issues, in theface of rising Medicare costs, the Government has become increasinglyenergized to seek healthcare savings from the touted efficiencies thatEMRs could bring.

Employers

Managed care was the beginning of trying to lessen healthcare premiumsto employers by measuring the quality and necessity of tests andprocedures. The increasing pressure of globalization on businesses hasput them squarely behind any initiatives that would increase themeasurability of the services they are buying.

All of the above were compelling reasons as to why EMRs would bevaluable to society. They addressed the societal advantage ofcomputerization without thoughtfully addressing the usability issuesfacing the physician. Like the first car builders who thought the carshould be steered with horse reins, the EMR was designed around thechart.

As noted before, the focus of all EMR designs has been on the chart andcharting. There was no standard across physicians, even within the samespecialties. The most common design for note writing was S.O.A.P. whichwas at best used by 50 percent of M.D.s, and therefore programsformatted on the S.O.A.P. Weed method required greater than 50 percentof M.D.s to change their habits. Many EMRs adopted problem-specifictemplates which were useful for first time visits but failed infollow-up notes. This failure was critical since the vast majority ofvisits are follow-up visits. Others adopted a blank text field and usedshort hand techniques to auto-generate text. As with the template-drivennotes, the S.O.A.P. and free text with “short hand” failed miserably inthe follow-up visits.

In addition, the structure of these conventions led to boiler plate,often bulky notes that either regularly repeated past text to the pointthat they were often inaccurate. To save time, some physicians justtyped in terse free text notes that often do not provide sufficientdetail to truly describe what the M.D. had just done. While the computerprovides greater legibility, the narrative is often lost in the samenessor incompleteness of the note, i.e. a long note that says almost nothingnew (for the third time in a row) or a short note that is bereft ofdetail.

Aside from poor market adoption, there has been provocative literaturethat questions designing EMRs around the chart structure. For instance,Edwin Tufte, an authority on the representation of data sets in logicalpatterns, has strongly spoken out against the design of the chart as abasis for an EMR. His quote, “the chart is a data dump, it was notdesigned with the care of the patient in mind” identifies the problem ofdesigning an EMR around the chart. His solution of a graphicalrepresentation with differential weighting of data based on the timeelements is not the correct solution, but it does identify the problemwith standard chart based design head on.

In addition, The Journal of the American Medical Association (JAMA)published an editorial in March 2005 highly critical of the currentchart based designs. See R. L. Wears & Marc Berg, Computer Technologyand Clinical Work Still Waiting for Godot, J. Amer. Med. Ass'n,293:1261-3 (2005). This article recognizes the problem that currentdesigns create on physician workflow, and questioned claims thatcomputerization of the note was having a net positive effect on patienterrors. It appeared that the problems it solved were replaced withproblems it created. Users were clearly hindered by the requirements ofthe system and its focus on the format/structure the program funneledthem into, rather than funneling knowledge and workflow enhancements tothe user.

This design can have serious, negative effects at the hospital bedside.This was illustrated in two publications in 2005. An article inPediatrics from December 2005 questioned the safety improvements thatcomputers are supposed to provide. In this article, an EMR was shown toactually increase the death rate in a pediatric intensive care unit(ICU). See Han et al., Unexpected Increased Mortality afterImplementation of a Commercially Sold Computer Order Entry System,Pediatrics; 1506-12, Vol. 116 No. 6 (December 2005). As noted in thearticle, computerization has increased the time it takes to document thevisit. This documentation time decreases doctor-patient time. In an ICUsetting, where each minute counts, this can be the difference betweenlife and death.

A second article addresses this time problem directly. A review fromSeptember 2005 analyzed the time physicians spent documenting notes andwriting orders in all published reports on EMRs for the last 20 years.See L. Poissant, et al., The Impact of Electronic Health InformationSystems on Time Efficiency of Physicians and Nurses: A SystematicReview, J. Am. Med Informatics Assoc., 505-16 Vol. 12 No. 5(September/October 2005). This extensive review documented a range ofincreased work for physicians, from 98 to 328 percent per working shift.The average increase in time spent documenting the encounter andordering necessary tests was 238 percent. This increase in documentationtime logically effects doctor-patient time and helps explain thefindings in the Pediatric article. It speaks volumes as to why there hasbeen poor adoption of EMRs/EHRs.

Despite decades of efforts, billions of dollars of investments,government mandates, etc., the benefits that EMRs could provide patientsand physicians have been minimized due to a serious design flaw. Theflaw is that they are documentation- or chart-based.

In discovering and resolving this design flaw, the Applicant willadvance the entire medical field/domain. Properly implementing ProblemSolving Process Computing will have similar ramifications to allknowledge fields/domains.

SUMMARY OF THE INVENTION

In accordance with one aspect of the invention, a computer implementedproblem solving system utilizing an information storage infrastructureand a flexible development environment for data storage, comprises astored, user modifiable program including a problem solving rule setrelevant to a problem to be solved, a stored, user modifiable set ofvocabularies related to a problem to be solved, at least one stored,user modifiable knowledge set relevant to a problem to be solved, andstored, user modifiable individual user preferences relevant to aproblem to be solved.

In accordance with another aspect of the invention, a computerimplemented problem solving method utilizing an information storageinfrastructure and a flexible development environment for data storage,comprises generating screen displays on a display screen; entering aproblem identified by an initial assessment to said computer at adesignated place in one of said screen displays; selecting from at leastone of said screen displays at least one item from at least one of: astored, user modifiable set of vocabularies related to a problem to besolved, at least one stored, user modifiable knowledge set relevant to aproblem to be solved, and stored, user modifiable individual userpreferences relevant to a problem to be solved and entering said atleast one item to said computer at a designated place in one of saidscreen displays.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

FIG. 1 is a diagram showing components of an initial medical encounter,with history, exam, assessment and plan(s).

FIG. 2 is a diagram showing how knowledge, both personal and universe ofknowledge, is applied to each segment of the chart.

FIG. 3 is a diagram showing orientation is fundamental to follow-up ofall problems and includes review assessment and plans, evaluate statusand make new assessment.

FIG. 4 is a diagram showing the components of the face sheet, used inthe process as a contextual orientor, with problem specific toolsavailable to help solve problems.

FIG. 5 a is a diagram showing the status of each problem denoted by a“sun,” graphically summarizing the status of all problems.

FIG. 5 b is a diagram showing arrangement of problem bar tabs providesadditional visual orientation.

FIG. 6 is a diagram showing how the process is repeated over time tosolve problems.

FIG. 7 is a diagram showing the four frames that affect problemdefinition and decision making.

FIG. 8 is a diagram showing an overview screen shot of the iEMR facesheet.

FIGS. 9-71 show screen shots of various iEMR functions and displays ofdata.

DETAILED DESCRIPTION

Introduction

The problem solving process across many fields/knowledge domains followsa definable set of rules that occur in all cases, without exception.Trained professionals, in many knowledge domains, routinely follow theserule sets; without formally recognizing the process. Problem solvingprocess computing is a fundamental departure from current designs.Applied to the core level of program design, it will lead toefficiencies and interface enhancements not possible with currentform/output designs. This will be especially evident and efficient inprofessional fields/domains that have specialized knowledge sets andsolve problems over time.

In the “paper world,” which preceded the computerized world of today,there was no obvious efficiencies from following a “problem solving ruleset”. Therefore, it was never formalized or taught. As computer programshave attempted to transform the “paper based world”, the focus has beenon computerizing the output of the problem solving process, i.e. themedical note, the legal file etc. On the surface, this seemed logical tothe designers and consultants charged with the task, who surmised itwould seem natural; even welcomed by the user.

This design effort has led to new types of inefficiencies and clumsyuser interfaces, that provide generic more than specific computerworkflow enhancements. This approach has led experts in the field, suchas nobel laureate Herbert Simon to declare that real world problemsolving—that is the common problems of every day life and professionalwork—is not the same across knowledge domains and fields. Newell A, ShawJ C, Simon H A. Elements Of Theory Of Human Problem Solving. Psych Rev1956; 65:151-66; Simon H A et. al. Decision Making and Problem Solving.Report of the Research Briefing Panel on Decision Making and ProblemSolving. Research Briefings by the National Academy of Sciences.National Academy Press 1986 It has also led to a definition of problemsolving in the internet encyclopedia—Wikipedia—that agrees with thatpremise and even supports a view that problem solving in North Americais different than in Europe.http://en.wikipedia.org/wiki/Problem_solving. The patent applicantcontends that that all people solve problems the same way, regardless offield/domain or country of origin. Recognizing this, along with exactlyhow it is done, will have a fundamental effect on human—computerinterfaces. computer interfaces will appear to “think like we think”.

The patent applicant first noted this issue as a pilot test site for acomputerized medical record. In using this chart/chart note designedelectronic medical record (EMR), the patent applicant discovered thatthis design was inherently flawed. Faced with the inefficiencies thatthe chart based EMR design brought to the medical field, the applicantembarked on a deep analysis of the problem solving process that wasbeing done, but not formally recognized, in the “pen and paper world”.This discovery led to the patent applicant discovering the unique set ofrules that drive the process of solving problems over time in allfields/domains.

Once discovered, it was postulated by the patent applicant thatprogramming these rules would gain efficiencies not possible with othertraditional computer programs and substantially advance the field ofcomputerization and all fields that use computer programs. This wasaccomplished by “reducing” the field/domains to their basic work units:problem solving, vocabularies, knowledge sets and individual userpreferences. In so doing, the software becomes scalable and naturallyintuitive. To most practitioners, it will appear to be “the way theythink,” as they practice within their field/domain.

It is the patent applicant's contention that software programs designedaround the problem solving process will provide a transformationaltechnology that will enhance the productivity of all computer users, andmost dramatically, knowledge workers who solve problems over time. Toprove this postulate, the patent applicant embarked on applying it tothe field/domain of medicine.

Medicine is a highly complex field/domain that takes years of trainingto become proficient in. It has the challenge of following data overdecades; resolving acute and chronic conditions; documentationrequirements with medical legal implications; and true life and deathsituations. It is also a field where adoption of computerized medicalrecord systems has had extremely limited success despite decades ofinvestment, research and strong external pressures to computerize. Itwill be shown that the entire field of medicine can be “reduced” to a“problem solving process” or problem solving process computing (PSPcomputing). PSP computing distills the entire field of medicine to the“problem solving process,” with all its necessary outputs or charting(documentation/prescriptions/orders/instructions/alerts/scheduling/tasks)automatically produced as a by product of solving the problem(s).

In demonstrating this process working in such a difficult, diverseproblem driven field/domain as medicine; the patent applicant contendsthat this same problem solving process can do the same in anyfield/domain that solves problems over time. The application willprimarily show this concept related to medicine, but will showscreenshots of other fields/domains that could be converted using thesame principles. Specifically, we make further claims that the exactsame process can be applied to any field/domain, i.e. law, real estate,consultancy, computer programming, detective work and many more) thatsolve problems over time.

The Problem Solving Process

The next section defines the rules of problem solving processprogramming. following these problem solving rules fundamentally changesthe human-computer interaction focusing on the true work of thefield/domain while automatically delivering any needed documentation.

PSP-based computing enables the user to be constantly in the “decisionmaking mode” rather than the “data gathering, literature review,decision making, followed at the end by documentation mode” of standardpaper and system designs currently available. The user has standarddomain knowledge sets pre-populated around the problem sets theindividual user sees in their practice. In addition, the inventioninherently “learns” continually from the user what “domain subset of theuniversal knowledge around each problem” the user selects to solve theproblems based on their own individual experiences and preferences.Aside from this, all they need to add is their “local knowledge,” i.e.addresses and names of sub-specialists and other “plan providers” and“local knowledge around the client/patient” like pharmacy, insurance,formularies that affect the problem solving plan choices.

Why are computers difficult to use for most people? Current computerdesigns “think” like computers, not like humans. In the course ofoptimizing the PSP computing, it became obvious that computers were notjust designed around the output of our work; they were designed aroundhow computers organize and use information.

People think in neural nets of interconnected nodes that quickly tell uswhere we left off with people or things in our environment. In addition,human neural nets use this knowledge with goals in mind. These goals areeither quickly reached or based on feedback, the person assesses thatthere is a problem, and redirects their thoughts with new plans to getthe desired result. There are numerous examples of this in our day today activities, in fact, it is happening constantly. There are very fewprocesses in the human mind that do not go through the following:

-   -   A. A prompt of some sort sets off a neural net; this may prompt        further nodes.    -   B. The nodes are evaluated, and trigger a goal directed action        such as:        -   1. More information needed, will look for more now or later,            from either with more thinking or external sources, possibly            queue for now.        -   2. Action needs to be taken, physically, verbally, or            mentally.        -   3. No more information needed, goal is reached.        -   4. Goal of current node less important than next node that            has come up automatically or via interruption, and node is            dismissed.

Even “automatic” functions go through a rapid fire assessment of thesituation as a Plan is initiated. For example, if you were urinating,and someone knocked on the door, you would likely have a short decreasein urine output as you assessed this “unexpected interruption” of yourplan to empty your bladder. You would quickly scan and assess that thedoor was locked; you would likely verbalize your presence, and in amatter of seconds, resume the “task” at hand. Or, when you are lookingfor a paper on your desk, you use prompts from your neural net thatgives you an approximate idea of where you left the paper. As you pagethrough the papers on your desk, your brain is rapidly, almostsubliminally, going through a goal directed identification processsaying “not it” to each paper you see. It does this until it reaches thepaper you had set out to find.

Even in conversation, the goal is to make a point, tell a joke orexpress an emotion. An internal mental assessment of how well you arecommunicating your points to your colleagues or friends is going througha rapid feedback and adjustment process automatically. This leads tonearly automatic changes in your emphasis/facts broughtforward/inflections/body language/and emotions as you try to reach yourgoal in the verbal interchange.

In contrast, computers “think” in terms ofroot-tree-branch-leaf-vein-node knowledge locations. The node is thelast place they get to! Compounding this, they go to nodes one at a timewith no “a priori” knowledge of how they are interconnected. They lookat data as data; Goals are not inherent to computer programs. Theirvirtue is their exact recollection of the finest detail. Unfortunately,for humans to get at this detail, they are always forced to navigatesome level of the root-to-node path. Even the best designed computerprograms only collapse this structure to a small extent, getting youclose to what you want some of the time.

As stated above, computer programming is not inherently goal directed asis human thinking. They only have goals to extent the programmer is ableto understand and customize predetermined scenarios. If usercustomization is available, it is generally an additional job to do,situation by situation, rather than allowing customization on the fly,without intrusion.

To truly interface with humans at the highest level, especially in anyform of knowledge work, a problem solving i.e. goal directed process,must be at the root level of computer design. The design needs to:

-   -   1. Incorporate the structure of nodal neural nets: “collapse the        tree” by gathering for the human, the nodal information needed        to prompt the person where they left off with the problem. In        addition, it needs to provide all additional “orientation” to        the problem in context, automatically.    -   2. “Learn” each individual's problem solving goals as the person        uses the computer. The program needs to be able to “learn” how        the user is interacting with the computer to solve problems. It        needs to log what parts of the program they are using. Then it        has to have an efficient trigger that allows the user to capture        the knowledge and steps they used for that problem, so they can        be more efficient the next time. This should be a fluid part of        the process, not an extra step or an annoying prompt.    -   3. Bring forward problem specific problem solving tools/actions        that the individual personally uses already, with access to        additional problem specific tools/actions that the user has not        personally used.    -   4. Have a status marker available to allow the person to        individually assess the state they are leaving the problem in.

Currently, when you want something on a computer, computer programs makeyou adapt to their “thinking”structure. This is an inherent 20 and21^(st) century computer programming design inefficiency which iseliminated with PSP programming. Instead of adapting to computerdesigned “efficiency” such as “phone menus,” think nodal “thinking”.

When you want something on a computer, computer programs make you adaptto their “thinking” structure. This is an inherent 20^(th)- and21^(st)-century computer programming design inefficiency which iseliminated with PSP programming.

What does node level thinking mean? This might be best exemplified bylooking at a simple example outside of the medical field. Consider aperson who every week withdraws various sums from A.T.M. A PSP designedA.T.M. would be enabled to “learn” from the user what problem they aretrying to solve, seamlessly. In this case, the problem is that 98% ofthe time the person goes to the A.T.M. to get exactly $200, $300, $500or to make a deposit. Currently, the only “intelligence” offered is theability to set up a single memorized withdrawal amount. Even thisrequires a separate job for you to do to set this up for futureshortcut.

In most A.T.M. situations, you have to follow a somewhat “collapsed”tree structure to get the money. The human is forced to go through aprocess that mimics how the computer thinks about the transaction ratherthan the way the person does. In short, you drive up to the A.T.M.already knowing you want a particular sum of money based on yourperceived cash needs in the next few days. This is based on otherfinancial “nodes” that you run through quickly in your drive up to theA.T.M. These thought “nodes” are rapidly put through a goal directedproblem solving process, subliminally, to determine the goal of the $amount you calculate you will need). By arrival, the human knows theamount they want before they put their card in. Over time, these amountstend to be just a few possibilities that the computer, if trulyefficient, would learn from the human. Instead, except for the simplestof situations, the A.T.M. forces you to follow its instructions in asomewhat “collapsed” root-tree-branch-leaf-vein-node process to get whatyou want.

In this example, the current structure requires you to sign in and touchwhat type of transaction you want from a menu. In this case the usertouches “withdrawal”, the user is then presented with the branch, thatis, a choice between checking and savings accounts; the leaf “checking”is selected. Then they pick from nodes representing “table of possibledollar amounts”, and then click “done”. This is followed by anotherbranch that wants to know if you “need a receipt?”

Now, let's take a PSP approach to this simple human/computerinteraction. The PSP approach would let the user “macrotize” anyrepetitive function they do around a problem they need to solve. In thiscase, the problem to be solved is getting out your money as quickly aspossible from the A.T.M., not a dollar less or more than you want. Theuser would have the ability to set up “on the fly,” a macro thataccomplishes this. Following the same steps as above, the user isallowed to name the “process” of getting his or her “dollar amount” bynaming these transactions at the completion of any A.T.M. withdrawal, ifthey desired. Over time, they would have as few, or many of suchmemorized transactions presented to them upon inserting their A.T.M.card.

Following the same steps as above, the user is allowed to name the“process” of getting his or her “dollar amount” by naming thesetransactions at the completion of any A.T.M. withdrawal, if theydesired. Over time, they would have as few, or many of such memorizedtransactions presented to them upon inserting their A.T.M. card. Withthis design, in a very short while, the A.T.M. “would learn” how tointeract with you in most cases, and present the following display soonas you put your card in:

Do you want

-   1. My usual $200. No receipt. Then close?-   2. My usual $400. No receipt. Then close?-   3. $500 with receipt. Then close?-   3. Checking deposit. With receipt. Then close?    The person touches the $200 choice and is done. Less time with the    A.T.M.; more time with your money!

If a trivial situation like this takes several clicks, imagine thesituation an M.D. is faced with in root-tree-branch-leaf-vein-nodestructured ENMR's! Again, computers, by design, follow a root, tree,branch, leaf, vein, node mechanism to retrieve and write data. Thedifferences in how humans and computers process information is the mainreason why computers are perceived as difficult for so many people. WithPSP design, the computer still processes information the way they alwayshave; how they display it to the user is the difference. That is, withPSP computer programming, the computer can rapidly go through its root,tree, branch, leaf, vein, node process behind the scenes, and presentonly veins and nodes to the human. It can effectively collapse the treeor appear to turn the tree upside down. The computer screen will displaynode—node patterns, readily recognizable to humans. The effects willhumanize the computer interface. Learning curves, and “computer designintimidation” will be a thing of the past.

The Four (4) Fundamentals

There are essentially four fundamentals to problem solving in allfields/domains that solve problems over time. The first point that mustbe recognized is that in almost all knowledge domains, the patient orclient comes to the practitioner/consultant to have a problem orproblems prevented or solved.

The second point is to recognize that all practitioners in all of thesedomains solve problems the same way. Specifically, these practitionersapply specialized knowledge sets learned in training and experience witheach individual problem until that problem is prevented/resolved or atleast improved. If unable to resolve the problem, they exhaust allreasonable remedies before it is mutually agreed upon to stop. To theextent that the practitioner/consultant is able to accomplish this isdirectly related to their professional reputation in their field.

The third point is that the process is programmable. The PSP followsrules that Applicant has discovered to be universal. The Applicantcontends that the PSP is especially relevant to the field of medicine.See K. C. Meyers et al., The Follow-Up Note: Format and Requirements,Specifications for the Computerized Medical Record, AMIA Proceedings:Orlando, Fla. (1997).

The fourth point is that the “reduction” of these complex domains totheir core work units leads to an extraordinary increase in efficiency,scalability, and flexibility.

This leads to the impression that the program is actually intelligent.It appears to learn from the doctor and over time appears to think likethe doctor. This organically adaptive design will have a major impact onusability now and in the future. In fact, the organic nature of itsdesign predicts that the longer one uses PSP Computing in their work,the smarter it becomes.

2. Rules of the Problem Solving Process

Introduction

Problems are solved over time. Only rarely are they completely solved ina single encounter. In the medical field, even a hang nail that isaccurately diagnosed is not truly cured until the patient calls back ina week to confirm that it is gone and was not complicated by a secondaryinfection. The Problem Solving Process (PSP), universal to all problemssolved over time, is best expressed in the diagrams and their relatedtext. While these diagrams relate to the specifics of medical care, theycan be easily applied to other domains simply by changing the knowledgesets and the names/vocabulary of the “methods” in which the practitioneruses to organize their information/documentation.

In medicine, those methods are a standardized organization of a visitinto the following categories. These methods are well known conventionsused to compartmentalize the note, and are not an element we areclaiming in the invention. The methods include a History as anaccumulator for the first person account of the problem and aninterrogatory with the patient for relevant clues as to the etiology ofthe problem. The Exam is learned in the M.D.'s training to look forphysical clues indicating health or illness related to the problems athand. The Assessment summarizes the diagnostic possibilities of thecauses of a given problem, and the “why” regarding the plans. The Plansare the final step of the initial visit of the patient and represent theuniverse of possible medications, treatments, tests or consultationsthat can be given for that specific problem. This method can bedescribed by the acronym “H.E.A.P.” which stands for History, Exam,Assessment, and Plans. FIG. 1 thus shows the initial H.E.A.P. for anyproblem.

The convention in medicine follows some additional organizational rulesthat are generally, but not universally applied or required. Generally,there is only one history for each problem, and one assessment for everyproblem. There is one exam per visit, though their will be problememphasis within that exam. Even “doing nothing” is a plan, so there isalways at least one plan, but their can be any number of plans orderedfor a given problem.

Step 1: Knowledge Management

There is an intersection of the knowledge set around each individualproblem that drives the problem specific history, exam, assessment, andplans. As depicted in FIG. 2, this consists of the universe of knowledgethat can theoretically, with modern search mechanisms and evidence basedstandards, be made available for every problem. This universe ofknowledge can then be filtered down to a practical list of personalknowledge that the practitioner commonly applies to the problem. Thisknowledge base can of course be codified to further enhance the value ofthe documentation that is automatically generated as a result of theproblem solving process. This can be done in post visit and intra-visitdata analysis and decision support. For sake of illustration, K=universeof knowledge, k=parts of that universe the practitioner values and usesin their own methods and decision making process. The M.D. filterspersonal knowledge for each problem from the universe of knowledge,influenced by training, talent, education, experience, and continuingeducation. This knowledge can be applied to each segment of the chart.The M.D. can “add to or subtract from” their personal knowledge sets atany time. Understanding exactly how professionals use knowledge to solveproblems is fundamental to the PSP Computer Programming. By intuitivelyconnecting the universe of codified problem specific knowledge to theproblem, we add intelligence to the problem solving process. Theexperiences and judgment of the practitioner now are amplified by theprogram in every area. To be specific on this point, here are examplesof problem specific knowledge as it is used in each section of themedical encounter:

History Section

Problem specific knowledge provides for key questions to be asked in thehistory section, questions that might be omitted if memory alone isrelied upon. For example, asking “if the patient is breast feeding, hasallergies or is possibly pregnant” can be life saving and is easilyomitted by the human brain. Putting this type of problem specific keyquestion knowledge in the history can prevent errors, especially thoseof omission. A secondary effect of this is the reduction of lawsuits.

Exam Section

Problem specific knowledge can provide problem specific exam lists inthe exam section. This can save a lot of time and again providesafeguards against forgetting to document important negative examfindings. This has both patient safety and malpractice protectionaspects.

Assessment Section

Problem specific knowledge is extremely important in the assessment. Theassessment is the area that a physician's skill in problem solving isput “on the record”. In a well written note, it reflects what the M.D.was thinking and explains why certain actions were taken. PSP computerprogramming has unique advantages by fully understanding and leveraginghow the physician uses their own knowledge and the universe of knowledgein the problem solving process. With the internet, there is virtually nolimit to the amount of knowledge available to the practioner at thepoint of care. In addition, this design allows the user to personalizethis knowledge by summarizing what is known from the universe ofknowledge about the problem and use it in their own personal knowledgelists or short/smart lists regarding the problem. This can be used tofully write the assessment/analysis of the problem and provideadditional details as to the “why” behind the plans being ordered, witha single click of the mouse.

For instance, this can be used to summarize any segment of the availableknowledge that the physician would use to analyze the diagnosis,management and potential complications of treatment for a given problem.Specifically, it can be used to discuss the possible complication rateof a recommended procedure, or the exact specificity/sensitivity datafor each plan recommended to diagnose and treat a problem. It can beused to discuss the underlying cellular mechanisms, or even the geneticbasis of the problem.

Plan Section

All sections in PSP computing utilize “nodal thinking” or “nodal dataorganization.” Nodal thinking is most evident in the plan section. Here,the PSP designed program leverages nodal thinking and provides the M.D.With a problem specific, ‘personalized’ list of plans with all thedetails of how they order them. With one click, they can order single orcomplete sets of plan(s) down to the finest detail. For instance the MRIgives the type of MRI, the location of the test with written drivinginstructions, the reason for the test, checks for medical necessity andwrites an order in one click.

This parallels and further amplifies the M.D.'s thinking at the nodelevel. Specifically, the M.D. Has a patient with a headache that hewants to have an MRI done at one of the 3 hospitals he or she goes to.With one click the M.R.I. is ordered and clear instructions are writtenon how to schedule it and get to the testing facility; in addition,medical necessity is cleared, and any needed prescription is written. InPSP computer programming, this is automatically provided withoutadditional steps. The M.D. solves the problem; all needed forms anddocumentation automatically occurs.

In this case, the nodal thinking of the practioner is not only matchedby the program, but in providing all the aforementioned outputs, it isgreatly enhanced. The M.D. Does not feel obligated to help find thephone number, recommend that the patient call for directions, etc. Allof this is a “part of the problem solving process”. What good isrecommending a test if the patient does not find the facility, or findsout later that the insurance will not cover it? This marrying of “humannodal thinking” with “computer nodal thinking” will create efficienciesand insights not possible with current designs.

Step 2: Minimum Work of the Follow-Up Visit and “Orientation”

The minimum work (as defined by K. C. Meyers et al., The Follow up note:Format and Requirements, Specifications for the Computerized MedicalRecord, AMIA Proceedings: Orlando, Fla. (1997)) is placed in theorientation section in all follow-up visits. This fundamental rule, forevery problem, is as follows:

-   1. The M.D. Must review their last assessment and plan(s) for the    problem-   2. The M.D. Must review the plan results for that problem that have    completed since the last visit-   3. The M.D. Must inquire about, or evaluate the current status of    the problem    Once this is done, if the problem status is resolved/cured, the    visit would be complete for that problem even if nothing else is    done. Hence the name “minimum work of the visit”.

If the problem is not cured, then the M.D. will minimally make a newassessment and plan. If necessary, the M.D. will do an interim historyand exam (PX—short for physical exam), on the patient in relation to theproblem. As expressed by this author in his article (K. C. Meyers etal., supra), these steps are crucial to the solving of problems overtime. Together they are called “orientation”. The author contends thatthis orientation process is not unique to medicine and is used in allproblem solving done in all fields/domains that solve problems overtime.

As expressed by this author in the article, The Follow-Up Note: Formatand Requirements, Specifications for the Computerized Medical Record,the three steps of the “Orientation” section are crucial to the solvingof problems over time. The author contends that this orientation processis not unique to medicine and is used in all problem solving done in allfields/domains that solve problems over time.

FIG. 3 depicts a diagram of an initial visit followed by another visitshowing the position that orientation takes in the follow-up visit.

Step 3: The Process Repeats Until the Goals of the Problem SolvingProcess are Reached

It is very important to realize that the above process repeats itself,ad infinitum if necessary, to reach the mutual goal of the patient anddoctor to stabilize/cure the patient. The orientation, which can beviewed as a standardized way of “starting where you left off”, is acritical piece of programming that needs to be in every computerizedproblem solving process engine to be effective. It matches the logicstream and process of the M.D. Who is seeing the patient and completelyeliminates the need for the building of clumsy templates for the 2nd,3rd, 4th, . . . nth visit for each individual problem type.

Step 4: Orientation Beyond the Individual Problem—the Face Sheet andProblem Solving Tools

Important adjuncts to “orientation” around a problem includes theability to instantaneously get a complete view of the problem inrelation to past assessments and plans for the problem, other problems,the severity of the individual problems, historical tables, allergiesetc. At the time of the orientation along with the timeline of theproblem. This is accomplished by creating a face sheet around all theproblems and providing problem views that include prior assessments andplans.

The face sheet (see e.g. FIG. 7) gives you additional orientation bypresenting information on other unique properties this patient has inaddition to the problem currently focused on. The M.D.s then adjusttheir diagnostic and management strategies based on how these elements,along with other plan results, influence the problem's resolution. Forexample, chest pain in heavy smoker over age 60 with diabetes willdictate a different strategy than a patient who is a nonsmoker, age 30who also has chest pain.

In addition, problem solving tools are all the possible things the M.D.Will use to prevent/diagnose, stabilize/cure a problem. This includesplans, literature, free text, and other forms of knowledge which areattached to each problem from the M.D.'s personal knowledge list (whichhe or she obtained from the universe of knowledge available to thisproblem). In the aforementioned chest pain, the differential diagnosisof chest pain could be added to the note with a single click and theplans for treating and diagnosing the chest pain (such as stress test,cardiac enzymes, cardiology consultation), with all needed documentationwould be available in a single click.

The diagram of FIG. 4 illustrates problem solving tools connected to theproblem along with all other necessary information to consider theproblem in context while seeing a patient for the problem. FIG. 5 a is aschematic that shows how PSP computing inherently orients the user towhere you are at in the Process at all times. As shown in FIG. 5, thepatient has three active problems looked at in the first visit: chestpain, preventive health, and hypertension. The chest pain is the onlyone in the diagnostic phase of problem solving. The next visit (Visit 2)reflects Plan results that have transformed chest pain into thediagnosis “angina.” Now it is at the beginning of the management phaseas denoted by the sunburst symbol. In FIG. 5 a, the status of eachproblem is denoted by a “sun” graphically summarizing the status of allproblems.

Step 5: Timeline

Problems are “prevented/diagnosed” and “stabilized/cured” over time.This implies there is an onset of the problem. This needs to be capturedand relayed to the M.D. as part of the orientation process. In additionto an onset date, the timeline will also display when the M.D. first andlast saw the patient for this problem. Furthermore, the timelinesignifies the reality that the M.D. is often not personally seeing thepatient at the onset of the problem. There are many instances that theM.D. is seeing the patient later in the course of the problem. Thepatient has already has had evaluations and treatments for the problem.This fact further complicates template-driven EMRs as they try to builda one size fits all template for most problems.

Step 6: Stages of the Problem

Some problems in other domains are clearly identifiable at the onset andare only managed until they are resolved. For example, an accountant maybe doing your taxes and interacts with you two to four times until yourreturn is done. This is all problem solving done in the managementphase. In medicine, the problem always goes through two phases. Thefirst is a “diagnostic phase” where the problem is diagnosed with a highdegree of certainty using the process just described. The second is“management phase,” where again the same process is used until it isresolved.

In addition, every problem, like a book, has a beginning, middle, and anend. Recognizing this concept allows for more detailed programming ofthe problem solving process. We contend that we are additionally uniquein recognizing this. In so doing, the program is further able to assistthe M.D. By nesting knowledge not just by the problem, but also based onwhat stage the problem is in. For example, the knowledge used for breastcancer early in the management phase just after a lumpectomy andirradiation is different then the knowledge used in the same patientwith breast cancer after they are later in the management phase and theyhave failed 3 different chemotherapy regimens. This has implications inall knowledge fields/domains.

Step 7: The Orientation Effect of “Problem Status”

The status of the problem is a powerful orientor in itself. Our focus onthe problem solving process has given us unique insights in creatingprompts that give maximum usability and data organization by design.

Referring for example to FIG. 8, we use a unique problem bar, where theproblems are prominent, individual tabs across the top of the page(elevating them to the highest level of attention). One insight wasdevising a simple color scheme, red, yellow and green (shown in FIG. 5b) to clearly delineate the importance/severity of the problems, as morefully discussed below. This elegantly tells the M.D. where the problemis in terms of the diagnosis/management process This is a powerfulorientation tool. By design and organization, the physician instantlyknows what to focus their attention on. This is especially useful inpatients with multiple problems where it is not immediately clear whereone should start. The author has personally tended to patients withgreater than 25 active problems. This design was critical to efficientlycaring for them.

Step 8: Management Principles

This process is also unique in recognizing that every problem in themanagement phase has three principles to monitor and bring knowledge tothe M.D. that is, the M.D. is primarily interested in the management ofthe problem, but also must constantly be aware of the complications ofthe problem and in addition the complications of the plans/treatmentsused to stabilize/cure the problem.

This is supported again by clustering knowledge around these principlesthroughout the management phase of each problem. An example would be apatient with diabetes and renal insufficiency secondary to the diabetes,getting a CT scan with dye infusion. This has a high risk of worseningthe patient's kidney function and potentially causing permanent renalfailure. A PSP EMR would have knowledge of the associated complicationsof diabetes such as renal failure. It would also have knowledge of whatare the possible complications of the CT scan with infusion. Pullingthis together the M.D. could be alerted to this and have treatments suchas extra intravenous fluids and acetylcysteine brought forward forordering to help prevent worsening of the renal insufficiency.

In short, the knowledge that could be loaded in the PSP would “know” thepossible complications of disease and plans/tests. It would also “know”potential “antidotes” and bring those “antidotes” forward for immediate,single click entry. In so doing, it would efficiently protect thepatient, prompt the physician and save time.

Step 9: Problem Solving Goals

The goal of all problem solving, medical or otherwise, is to resolve theproblem. In the medical world, this resolution goes through two stages,diagnosis phase and management phase. The processes described above arerepeated over time until a diagnosis is made. Some management is doneduring the diagnosis phase, as a tentative, interim diagnosis is oftenstated to guide initial treatment. Once the diagnosis is precisely made,the management phase is begun in earnest.

For most problems, beginning the management phase leads to a new, oftenmore detailed evaluation in terms of treatment considerations with agoal of stabilization or cure. The process repeats as clearly describedabove until that goal is reached or it becomes clear that the goal isnot attainable. Even though “cure” is the ultimate goal, a minimum goalof “stable” is often accepted when the state of the art of problemsolving for the illness does not lend itself to a cure; for example,type 1 diabetes, hypertension, or metastatic cancers. In these cases,the problems will remain on the problem list with continued attempts tomake them as stable as possible. Ultimately in all humans, some problemis not solvable, and it leads to the demise of the patient.

The PSP thus is universal for all problems from birth to death in themedical field/domain. It is also universal in all fields/domains thatsolve problems over time.

The elements just described are depicted in FIG. 6. The Problem SolvingProcess is repeated over time with each problem until they arediagnosed. The PSP is again used in the management phase the exact sameway with the relentless goal of problem resolution or at leaststability. Again, this process is not unique to medicine and it isbroadly applicable to all problem solving disciplines and will providegreat efficiencies to all domains it is applicable to.

Thus, by “reducing” the complexity of medicine to these elements, eachproblem is solved and the clinical charting “automatically occurs” as aby-product.

Framing the Problem

Aside from following the above rules of problem solving, the patentapplicant has recognized the importance of “framing” in regards toproblem solving. This is a significant reason that the problem solvingprocess has not been recognized as common to all problems andprofessions. It explains why problem solving appears to be differentbetween North America and Europe and between different religious groups.It is the problem framing that these groups apply that differs, not theproblem solving process.

Problem framing reveals that there are external constraints on allproblems that effect both “what is considered to be the problem” and“decision making”. This has led to a focus on programming all theconstraint variables rather than recognize and leverage the problemsolving process. Instead of utilizing the innate problem solving processthat all humans use throughout their day, “artificial intelligence”programs try to anticipate all possible constraints that effect decisionmaking. This is exceedingly difficult to do, and a nightmare tocompletely personalize for all the states a problem can be in. Thepatent applicant has accounted for the effects of framing on problemsolving and contends that these constrains are external to the problemsolving process, and do not change its function. It only changes theexact decisions made, based on the influences of framing. Problemframing is exemplified as follows:

There are essentially four frames that guide the PSP: (1) culture, (2)experience, (3) personal, and (4) resources. The “culture” frameaccounts for external constraints such as religious, national, ethnic,corporate, legal, etc. The “personal” frame accounts for externalconstraints such as motivation, desire, energy, talent, gender etc. The“experience” frame accounts for external constraints such as knowledge,quantity, or quality of past experience. The “resources” frame accountsfor external constraints such as personnel, cost, and equipment.

Each frame has individually-defined, variable effects on the problemdefinition and decisions made. This is why artificial intelligenceprograms have great difficulty replacing the “human factor.” Even rightand wrong have personal/cultural underpinnings. Each person has tobalance these constraints as they are presented with any problem. Theinfluence of each frame can be immense. However, once a problem isdefined, the impact of the framing will then be on the actual decisionsmade over time but not the PSP.

EXAMPLE 1 Cultural Constraints

As an example of how framing works, let us take the example of how anM.D. views the problem of a hemorrhaging patient, who happens to be aJehovah's Witness. From their training and experience, the M.D. willknow that in order to stabilize this bleeding patient, the M.D. willneed to be given the patient more blood. When the M.D. tells the patientthat he or she needs blood, as there is a high likelihood of bleeding todeath, the patient frames the issue in a personal/cultural way thatplaces religious constraints on the possible plans available to solvethe problem. The patient actually views the problem not just as alife-threatening gastro-intestinal bleed. The Jehovah's Witness view ofthe doctor's recommendation is a far greater problem due to theseframing effects. It is viewed as “eternal damnation” if the M.D.proceeds along their normal problem solving mode.

The patient views the situation in a much different view than the M.D.The Jehovah's Witness patient frames the situation with the personal andcultural (religious) constraints and believes that if blood is given,survival likelihood is increased but the patient will have to endureeternal damnation. Thus, the patient refuses treatment. The M.D. isforced to take the most common solution to this uncontrolled bleedingoff of the possible solutions list for this individual patient. TheM.D., then, would review the prior law on the situation, reflect on theHippocratic Oath and decide that blood transfusion is not an option.Instead, the M.D. would use increased resources to try to capture thepatient's own blood for auto-transfusion.

EXAMPLE 2 Corporate Constraints

How an individual may solve a problem is often subjugated by corporaterules (culture) and financial constraints (resources). These constraintsaffect what is defined as the problem, and it affects the available planoptions, but not the PSP. In the corporate setting, corporate culturewill generally overrule the personal frame and sometimes even knowledgeas to what decision is made. In addition, financial resources are oftena significant restraint.

EXAMPLE 3 Experience and Training

Problem solving in any field/domain that requires training can be muchmore efficient if the client sees an expert with proper training andvast experience. These also frame the problem and greatly effectdecision making. If this is combined with personal framing factors suchas empathy, motivation, communication skills, etc. it can lead tooutstanding problem solving outcomes for the client/patient in recordtime. Still, the PSP is not affected. With professionals, lawyers,scientists, M.D.s, etc. the “experience” and “knowledge” along withpersonal drive tend to have the largest impact on problem solving. Thisoften leads to rapid problem solving which benefits clients and securesreputation of the practitioner.

4. The Intelligent Electronic Medical Record: I.E.M.R.

To display all of the concepts just discussed, the author has programmedan electronic medical record completely around the problem solvingprocess. No matter what problem the M.D. is trying to diagnose orresolve, the process is the same. PSP computing dynamically channelsinformation to the practitioner. This both simplifies and amplifies theproblem solving process as it tells the m.d. Exactly where they leftoff. It also provides problem solving tools that prompt, direct and aidthe physician in preventing/diagnosing and stabilizing/curing thepatient. The latter is the goal of all medical encounters.

FIGS. 8 to 71 show screen shots of the intelligence of this process inthe medical domain. A fully functioning EMR has been built on theseprinciples and if desired, the applicant would be more than willingdemonstrate it live. The PSP dynamically channels information to thepractitioner. This both simplifies and amplifies the problem solvingprocess as it tells the M.D. exactly where they left off. It alsoprovides problem solving tools that prompt, direct and aid the physicianin diagnosing and curing the patient. To display all of the conceptsjust discussed, the author has programmed an electronic medical recordcompletely around the problem solving process. No matter what problemthe M.D. trying to diagnose or resolve, the process is the same. PSPcomputing dynamically channels information to the practitioner. Thisboth simplifies and amplifies the problem solving process as it tellsthe M.D. exactly where they left off. It also provides problem solvingtools that prompt, direct and aid the physician in preventing/diagnosingand stabilizing/curing the patient. The latter is the goal of allmedical encounters.

The screen shots illustrate features of a computer implemented problemsolving system utilizing an information storage infrastructure and aflexible development environment for data storage, comprising a stored,user modifiable program including a problem solving rule set relevant toa problem to be solved, a stored, user modifiable set of vocabulariesrelated to a problem to be solved, at least one stored, user modifiableknowledge set relevant to a problem to be solved, and stored, usermodifiable individual user preferences relevant to a problem to besolved.

The set of vocabularies, said at least one knowledge set and saidindividual user preferences comprise a relational database includingplurality of tables having a table driven infrastructure. The systemalso includes a display screen, and the computer generates a screendisplay including user viewable and modifiable display portionscorresponding to the set of vocabularies, the at least one knowledge setand the individual user preferences. The set of vocabularies, the atleast one knowledge set and the individual user preferences may be usermodified by adding, editing, and deleting elements. User accessiblemeans in the screen display may be used for retrieving net basedinformation for adding to the set of vocabularies, the at least oneknowledge set and the individual user preferences. The program iscapable of tracking the adding, editing, and deleting with user, date,and data value information and for processing user requests to modifyusing rules governing relationships among the elements of said set ofvocabularies, said at least one knowledge set and the individual userpreferences.

A related computer implemented problem solving method utilizes theinformation storage infrastructure and flexible development environmentfor data storage and generates screen displays on the display screen. Aproblem identified by an initial assessment is entered to the computerat a designated place in one of the screen displays. The user selectsfrom at least one of the screen displays at least one item from at leastone of the stored, user modifiable set of vocabularies related to aproblem to be solved, the at least one stored, user modifiable knowledgeset relevant to a problem to be solved, and the stored, user modifiableindividual user preferences relevant to a problem to be solved andenters the at least one item to the computer at a designated place inone of the screen displays.

The illustrated embodiment comprises a system for creating an electronicmedical record using the computer implemented problem solving systemhaving an information storage infrastructure and a flexible developmentenvironment for data storage. The problem solving rule set is relevantto medical diagnosis and treatment. The stored, user modifiable set ofvocabularies is related to medical diagnosis and treatment, the at leastone stored, user modifiable knowledge set, and the stored, usermodifiable individual user preferences are relevant to medical diagnosisand treatment.

Referring now to the screen shots, FIG. 8 shows an iEMR Face Sheet,which is an amalgamation of general facts about the patient. This is anextremely useful view of a patient's problem in context with otherproblems and personal histories the patient has.

FIG. 9. Problem solving process, computing in medicine: in the case of acomplex patient like this, it is essential to approach each problem incontext. The face sheet: When the M.D. Attempts to solve a medicalproblem, the practitioner needs to place the problem in context of theother problems the patient has along with other pertinent information.The details of these different ‘minor but important orientors’ are shownin the following pages.

FIG. 10. The face sheet is an amalgamation of general facts about thepatient. This is an extremely useful view of a patient's problem incontext with other problems and personal histories the patient has.

-   -   (1) starting at 1 at the top of page, it shows the patients name        and other identifiers.    -   (2) number 2 is the problem list. This consists of all active        problems the patient has. This is an essential component of all        decisions made about the patient. For example, a back pain in an        80 year-old woman with a history of 2 breast cancers, has more        potential for a serious underlying cause, then a back pain in a        24 year-old woman with no problems on her problem list.    -   (3) vital signs represent current pulse, blood pressure etc. . .        .    -   (4) current medications and allergies are the 4^(th) component.        The information contained here needs to be considered against        every treatment decision.    -   (5) the history tables are discussed on the next page.

FIG. 11. The history tables represent several categories of history thatare relevant to the orientation and the problem solving process. Thetest history is one important category. It is a summary of recent planresults. It can be blood tests, consult, scans, angiograms, etc. In thisexample, highlighted via check marks are some examples such ascholesterol results, a consult letter and a bone scan.

FIG. 12. Family history is one of the additional history tables that isimmediately accessible on the face sheet. Knowing what diseases run in apatients' family has a definite effect on the probability of getting thesame illness in the patient. This patient has heart disease andhypertension in her family history. She happens to have both herself.This type of information helps alert the M.D. To relative risks andsways us if patient presents with “chest pain” or the like.

FIG. 13. Immune history lets M.D. know status of immunizations. This isuseful in letting M.D. know patient is up to date on vaccinations forproblem “preventive care.” It also greatly reduces possibility ofcertain illnesses such as influenza, tetanus when patients present withsymptoms that suggest those possible diagnoses.

FIG. 14. Past history is a summary of important medical events such assurgeries and hospitalizations. Social history shows the socialinformation such as marital status, smoking, drinking, exercise. Travelhistory displays foreign travel dates and places. Ob/gyn historydisplays past obstetric history.

FIGS. 15 and 16. Preventative care is always the 1^(st) problem,emphasizing its importance.

The “green outline” indicates problems that are stable or dong well. Thecolor coded “problem bar” clearly indicates to the M.D. by its design,what problems are the most serious. This is a simple, but powerfulorientor that helps M.D. or nurses focus on the right things first. FIG.15 shows M.D.'s notes for breast cancer diagnosis.

FIG. 17. In addition to the timeline, the problem brings forwardadditional orientation such as problem details and the last assessmentthe M.D. had for this problem. The M.D. needs to look at the lastassessment and plan. In this example the assessment of the breast canceron Apr. 15, 2006 was “no recurrence.” There were no plans ordered. Theonly thing absolutely needed to close out this problem is a new statusas shown on the next page.

FIG. 18. In selecting a new status for the problem the M.D. may becompletely done with this problem if there are no additional issues thepatient brings up. The M.D. can now focus on other problems the patienthas. The minimal work of the visit has now been completed.

FIG. 19. Orientation around a more active problem. (1) In this case,abdominal pain has led to tests that show the diagnosis to be acutecholecystitis. Selecting “orientation” on the menu on the left leads tothis problem solving process driven screen. (2) The timeline and courseis automatically displayed to M.D. The M.D. is “informed” as to how thispresented, when it was diagnosed from abdominal pain to acutecholecystitis. (3) In addition, the M.D. sees plans ordered for this,and the results of those plans are displayed automatically.

FIG. 20. One example of a user's “personal knowledge list” used to solveproblems is displayed here in the physical exam section. The M.D. hascreated several “1 click” macros that define the nodal level detail ofthe physical exam findings that this M.D. usually uses in patients withacute cholecystitis.

FIG. 21. The M.D. Could also select a problem specific macro in theassessment section. This is again, user defined and can be used wheneverneeded in patients with cholecysititis. There is a space available foradding any free text comments desired. Any of these comments, can besaved in a macro form if they are felt that they may be useful in otherpatients with acute cholecrystitis.

FIG. 22. The plan section is all about “nodal thinking.” In this settingthe M.D. knows what to do by training and wants to order new plans tofurther diagnose and treat the problem. In this case, the M.D. Selectsinformation on laparoscopic cholecystectomy that will guide the patientto a web site for more information and gives detailed

FIG. 23. These instructions occurred automatically as part of theproblem solving process. They can be as lengthy as or as short as theindividual M.D. Feels is necessary to convey the instructions. If therehad been prescriptions, they would have automatically been created aswell.

FIG. 24. Once “done” is selected, the note is automatically generated.Solving the problem was the goal, this is an automatic by product. Theefficiency of the PSP process is displayed, as no attempt was madeduring this patient encounter was to actually write a note. It wasentirely about solving the problem.

FIG. 25. As discussed, problems have a diagnosis phase and a managementphase. The diagnosis and management can also be further divided into a“early.”, “middle” and “late” stages. This allows the user to change theknowledge they use for this problem based on what phase and stage it isat. Let's look at back pain, early in the diagnosis phase as an example.

FIG. 26. In this case, the back pain is in the management phase, middlestage. The selections available automatically change to reflect this.The patient has failed to respond to 2 epidural injections. The M.D.Could decide in this situation to give one more epidural, and easilyselects that and documents the situation due to this context specificknowledge.

FIG. 27. Addresses the need for expert problem solvers to be aware ofcomplications of the problem. Treatments of the problems or tests done.In the case of atrial fibrillation, these complications can also benested with the problem. In so doing, this can alert the M.D. To theseissues and also provides prompts and text that can be easily added tothe note in the course of managing the problem. The coumadin used intreating the atrial fibrillation can be complicated by bleeding.

FIG. 28. The user can add problem specific knowledge to each problem inevery section of the program. In the plan area, this is done in the“smart plans.”/“short list” area. This list is a short list of nearnodal knowledge of what plan the M.D. Uses to solve the problem. In thecase of paroxysmal atrial fibrillation, it could be a medication, aconsultation, cardiac tests, or lab tests. The M.D. Gets the informationthat is put in this area from codified knowledge lists via the internet.Once found, the M.D. Can actually rename the item to the way they thinkof it, not necessarily the name assigned by the “coders.” This furtherenhances the ability of the program to help the M.D. Think like theythink.

FIG. 29. “right clicking” on any list area allows user to obtainknowledge from codified sources. In this example, the M.D. Selects amedication window from a medicine dictionary. From there, just typing inthe term they want to add, will lead to the drug name. Once selected itis added to the smart/short list.

FIG. 30. Smart plans/short lists are “near nodal” in structure. They arewhat the M.D. Wants, but still require one more bit of detail from theM.D. They also need to be done one at a time. This is similar to howhumans think, as closely related nodes will trigger each other to givemore detail on a thought. It also delivers prompts as to what can bedone for the problem. This is akin to human thought and is quite helpfulto the M.D. Converting this via a macro to nodal thinking and gettingeven greater production is displayed in the next few pages.

FIG. 31. The next time the M.D. Sees a patient with paroxysmal atrialfibrillation, the macro will be available. The M.D. Can name this macroanything that they want. In this case, it is named “echo glenviewamiodarone 200 mg QD #30 day”. To get to true nodal thinking, the PSPprogram must allow the individual user set their nodal preferences undereach problem, as they solve them. This way, the program gets moreintelligent with each encounter with a problem and with each encounterwith the M.D. In this example, the echocardiogram and amiodarone aresaved as a macro by the M.D. This means the M.D. Thinks they will usethis exact combination again, right down to the address for theechocardiogram and dose and quantity for the amiodarone.

FIG. 32. As shown here, the next time the M.D. Sees any patient withparoxysmal atrial fibrillation, this macro is available. The name of themacro is all the prompting the M.D. Needs to know exactly what plansthey have ordered. This not only writes the order, it writes theprescription and detailed plan instruction. It is also quite malleable.Double click on one of the plans it creates, any detail can be changed.Using this power, the productivity of knowledge workers will greatlyincrease. This is the personalization and promise of PSP programming andnodal thinking.

FIG. 33. The computer organizes data in a root, tree, branch, leaf,vein, nodal structure. The root is which hard drive or internet serverthe data is on. In this case, the c drive (1). The tree is all the“directories” on the drive. In this case, the local disk c is mycomputer”. The dashed like is the trunk of the tree (2). On the trunk,there are branches that are represented as folders. These folders canlead right to the node, but most often they lead to more branchesrepresented as additional folders (3). Veins are additional folders.They represent the concept when you “nested information” when thesefiles were saved (4). Double clicking on assessment screen gets youfinally to the nodes you have an interest in (5).

FIG. 34. Current programs attempt to collapse the tree and present theuser with a clear choice of what is needed to go further. Search enginessuch as google are a terrific example of this. Even this is not assimple as it could be, as it does not know exactly what problem the useris trying to solve, nor allows itself to be easily changed by the userto fit their needs, or keep a record of what searches were done aroundthis topic beyond the time the program was open. That is, if you werelooking up “problem solving process computing” it would give you ascreen like the following.

FIG. 35. Google “remembers” that you have used this computer before forthis search and it changes the color of the links you have selected. Itdoes not know what information you gained from these searches andwhether your current status is on solving the problem. It does not havea means of learning how your actions other than “where you have beenbefore”. While this is helpful, it is just scratching the surface ofwhat problem solving process computing can do.

FIG. 36. This is the opening screen from power point. It has, unlikeGoogle, a staggering array of choices for the user. It learns in only aprimitive fashion from the user. The user is forced to learn how tonavigate this vast array to get what they want. That means, if the“problem” is to make a power point for my patent application, it doesnot learn from my use of the program how to best suit my needs. Itsimply “stores” what I save. Wizards and the like do nothing to reducethe clutter and distraction that all these choices bring. Eventually,the human brain actually adapts to this structure if the person uses theprogram often. Their mouse and key strokes will become a collection ofnodes that give them fluency in using power point. Designed around howthe user solves problems and having the means and selections completelyuser definable would make this program far more powerful.

FIG. 37. PSP computing starts at the node level. Unlike people,computers can run backwards just as fast as they can run forward. It isonly a matter of programming it to the user, not forcing the user toconform to the program.

FIG. 38. The patient, Vira Muenster is an existing patient of Dr.Meyers. She has a new problem, “abdominal pain”.

FIG. 39. The new problem jumps to the front position on the problemlist, and Dr. Meyers now views it in relation to the rest of theproblems and the patients personal history tables on the face sheet.

FIG. 40. Voice recognition software is used to capture the history.Minor editing will be required, but the patent applicant feels thatvoice gives us the best means of “telling the patient's story”.

FIG. 41. Abdominal pain brings up “nodal” knowledge of exams the M.D.Has done in past for abdominal pain. One click of one of the macrosleads to the full documentation of the exam.

FIG. 42. The M.D. could also select a problem specific macro in theassessment section. This is again user defined and can be used wheneverneeded in patients with cholecystitis. There is a space available foradding any free text comments desired. Any of these comments, can besaved in a macro form if they are felt that they may be useful in otherpatients with acute cholecystitis.

FIG. 43. The discussion text appears here. Then in the note field, theM.D. Types or dictates a small statement that shows the M.D.'s feelingabout most likely possibility in this case. The last thing that the M.D.Needs to do is “status” the problem. In this case, due to uncertainty ofhow severe this problem actually is, the M.D. Marks it in the “red zone”and specifically labels it “under evaluation.”

FIG. 44. Abdominal pain is a difficult area for any M.D. and there areseveral plan macros to pick from to help with the work up and writingclear instructions and prescriptions. In this case, the M.D. picks thismacro, which orders antibiotics and a ct scan to prove the diagnosis.

FIG. 45. Detailed documentation automatically occurs as a byproduct ofthe problem solving process.

FIG. 46. The prescription is also a result of the problem solvingprocess.

FIG. 47. Since compliance with medications is a vital part of solvingproblems, a complete schedule of medications is created. This shows thenew medications, cipro and flagyll and when they should be taken inrelation to the other medications. Even pictures can be provided ifdesired.

FIG. 48. The nurse calls the patient in a.m. to get update on condition.She is presented with “exactly where Dr. Meyers left off”. She changesstatus to a “red zone” better, writes a short note and has finished herphone call.

FIG. 49. Dr. Meyers is oriented around his last encounters assessmentand plans for this problem (1). He also sees the nurses assessment forthe day before (2). He changes status to decreasing and writes a shortnote. He also sees the ct scan is back and it confirms diagnosis ofdiverticulitis (3).

FIG. 50. Dr. Meyers used the differential section of the program toswitch abdominal pain to the true diagnosis—diverticulitis.

FIG. 51. Now that problem has been switched to diverticulitis, the M.D.Gets a new knowledge list of macros to pick from related to thisproblem. The PSP program thinks like he thinks.

FIG. 52. Instructions are automatically created.

FIG. 53. The patient now sees dr. Winchester for “diverticulitis”. Thepresentation, onset, all assessments and plans from all health careproviders are automatically delivered to him in chronological order. Heknows exactly what has transpired and why the patient is there. There isno need to fumble thru a chart. Electronic or paper. Dr. Winchester canfocus on the patient, not the chart! This is a natural, and importantpart of PSP computing not available with current computer programdesign, so I will spend a few more slides detailing this information.

FIG. 54. The first thing presented to Dr. Winchester is the onset date.He also sees this problem started as an abdominal pain and was diagnosedas diverticulitis on Apr. 25, 2006. These are two very useful factsbrought immediately to his attention.

FIG. 55. He sees the assessment and plans from Dr. Meyers inchronological order. He sees his thought processes as to why he did whathe did, what diagnosis Dr. Meyers considered, what diets and antibioticswere prescribed. He sees the ct scan result, and he sees the referral tohim along with the note that he has seen her before for breast surgery.

FIG. 56. Any healthcare provider that makes an assessment on the chartshould have it read and considered as part of the problem solvingprocess. PSP computing as shown in the iEMR program displays thatinherent function of this design. In this case, it is the nurse thatcalled the patient last week. It can also be any and all healthcareproviders that “weighed in” on this problem. In this way, no importantinformation is lost, as the data displayed is the assessment and planand prior problem status instead of the whole note, it is notoverwhelming in volume and can be quickly assimilated by a doctor ornurse.

FIG. 57. When Dr. Winchester opens the physical exam section, he seesthe text from the Apr. 25, 2006 exam by Dr. Meyers, and notes thetenderness she had in the left lower quadrant and the negative exam forhernia and negative rectal exam. As she has told him she is nowasymptomatic, he spares her the rectal exam, and just examines herabdomen, which is normal.

FIG. 58. He picks from his own macros for diverticulitis, and in asingle click documents a normal abdominal exam.

FIG. 59. He now goes to his assessment discussion area. He has “commonstatements diverticulitis” that he uses for this illness. He also hasdetails of surgical procedures stored here to help explain the surgicaloptions if surgery is elected. In this case, he feels surgery is not anoption and uses a macro to document his thinking. He explains this toher in detail, as part of PSP.

FIG. 60. At this point, he uses voice recognition to add this line.Then, to complete the problem solving process, he clicks a “green”resolved on the problem status bar. At this point, he is done. Theentire visit is documented, and he has typed not a single letter. Theefficiency is being created by the problem solving process, byorganizing data and knowledge by how we think, not by how we writenotes. The patient and he are quite satisfied with the encounter as theyboth got whey they wanted. Problem resolution. The insurers get whatthey want, documentation.

FIG. 61. The patient sees Dr. Meyers again on May 17, 2006 in follow-up.He sees immediately what Dr. Winchester has said in his assessment. Atthis point, he reviews how she is doing and she says, “fine.” At thispoint, the episode of diverticulitis appears to be completely cured!Now, if he wishes, he can leave it on the problem list in the “greenzone” as “resolved” or “no recurrence”. He also has the option to select“mark problem resolved”. If he elects to do that, it takes the problemoff of the problem list. That, if it were always possible, is theultimate goal of all M.D.'s and patients, to cure the problem.

FIG. 62. The diverticulitis is now part of her past history and“inactive problem” list. The doctor can now put his focus on improvingupon other problems on the problem list. He will use the same processjust displayed with all of them. Just the personal knowledge lists foreach individual problem will change. This process based computing giveshim a photographic memory of the patient, a photographic memory of allimportant problem solving tools he has been trained to use, and a meansof tracking everything tried to solve the problem with a relentlessfocus on reaching the goal of stable or cured. Medicine, and alldomains/fields that solve problems over time can similarly be “reduced”to this process.

FIG. 63. Diagnostic/management process.

FIG. 64. Using the same process as in medicine, the real estate agenthas all necessary orientation to the problem automatically broughtforward. The status choices would be different, but the concept wouldremain the same. The agent could status the state of the sales progresswith each encounter.

FIG. 65. Macros and short list “personal knowledge” around the problemof selling the house can be applied to help solve the problem. Theprocess is not different than medicine. The difference is only thetraining experience and knowledge sets these professional apply to theirfields.

FIG. 66. Showing this same process in the legal field domain simplymeans a change in vocabulary and knowledge sources. The process isexactly the same. In this case, Kim Meyers, J. D. Sees a long timeclient, Lenore Pierce. He has represented her in her business and in herpersonal like as well with her will and health care power of attorney.She is in today with questions she has on the health care power ofattorney. The lawyer takes this time to update himself on her civillitigation that she is involved in. He sent her to a firm he uses forsuch matters, and is keeping a file on the case. The problem solvingprocess design makes getting updated on this issue nearly instantaneousfor the lawyer and he is now able to give her good counsel on what hecan do to help. This will be shown on the next page.

FIG. 67. With one click, the rules of the problem solving processcomputing completely updates him. He can easily pick a new status whichwould have legal terms such as “in litigation” or “settlement talksprogressing”. The terminology on status would be entirely up to thelawyer. Going to the plan section, he would have problem solving toolsat his disposal, just like in medicine or any other domain/field thatsolves problems over time using specialized knowledge and vocabulary.

FIG. 68. The lawyer quickly goes to the plan section and with one click,selects the plan. This creates a “to do” item for him, and theinformation he gets from completing this phone call will go right intothe “Pierce vs. Kowalski” problem, and will be seen in context the nexttime he, or anyone involved in the case follows up on this problem.

FIG. 69. The lawyer now goes to the problem of “health care power ofattorney” and sees the history behind that and current request. Hecomplies with her wishes after some discussion and he goes to plans onnext page to order the changes and print the documents she needs.

FIG. 70. The lawyer can now select the health care power of attorneyoption 1, which fits with her wishes of no feeding tube. The form isproduced for her and her son to sign.

FIG. 71. The phone call to Jim Andrews regarding her litigation willremain on his “To Do” list until he completes this “Plan” that is nowpart of the Problem Solving Process. Any note made from this PhoneEncounter will be nested under the “Pierce vs. Kowalski” Problem.

The patent applicant again claims that this process is broadlyapplicable to any problem solving domain/field. Computer programsdesigned around the problem solving process. PSP Computing represents atransformational technology. This will advance the human computerinterface into a truly “natural human interface” and lead toefficiencies that are not reachable with current form based andRoot-Tree-Branch-Leaf-Vein-Node designs.

iEMR

The problem-solving process and related EMR described in the abovediscussion are particularly adapted to run on an EMR system known asiEMR described in U.S. patent application Ser. No. 11/065,600 filed onFeb. 24, 2005, titled “Method for Advanced Data Management”, and UnitedStates patent that application Ser. No. 09/997,723 filed on Nov. 30,2001, titled “Advanced Data Manager” (of which the former application isa continuation-in-part), and in the paper Expert Knowledge Base DesignedUsing ER-Modeling Technique, Naeymi-Rad et al. (1986). The iEMR wasdeveloped by Intelligent Medical Objects, Inc., 60 Revere Drive,Northbrook, Ill. 60062

This application incorporates by reference U.S. application Ser. No.11/065,600 filed on Feb. 24, 2005, titled “Method for Advanced DataManagement”, and U.S. application Ser. No. 09/997,723 filed on Nov. 30,2001, titled “Advanced Data Manager” (of which the former application isa continuation-in-part), as if fully reproduced herein.

While the foregoing written description of the invention enables one ofordinary skill to make and use what is considered presently to be thebest mode thereof, those of ordinary skill will understand andappreciate the existence of variations, combinations, and equivalents ofthe specific exemplary embodiment and method herein. The inventionshould therefore not be limited by the above described embodiment andmethod, but by all embodiments and methods within the scope and spiritof the invention as claimed.

1. A computer implemented problem solving system utilizing aninformation storage infrastructure and a flexible developmentenvironment for data storage, comprising: a stored, user modifiableprogram including a problem solving rule set relevant to a problem to besolved, a stored, user modifiable set of vocabularies related to aproblem to be solved, at least one stored, user modifiable knowledge setrelevant to a problem to be solved, and stored, user modifiableindividual user preferences relevant to a problem to be solved, whereinsaid knowledge set is applied to diagnose and manage said problem, saidset of vocabularies are used to name tools for said problem diagnosisand management, and said individual user preferences are used toorganize said problem diagnosis and management tools; wherein saidsystem allows a user to evaluate said problem to be solved and providesoptions to said user to develop a plan to manage said problem to besolved, and further wherein said rule set includes iteration ofevaluations and plans, and said system orients said user to a status ofsaid problem to be solved at each iteration to allow said user to managesaid problem to be solved.
 2. A computer implemented problem solvingsystem according to claim 1, wherein said set of vocabularies, said atleast one knowledge set and said individual user preferences comprise arelational database.
 3. A computer implemented problem solving systemaccording to claim 2, wherein said relational database includes aplurality of tables having a table driven infrastructure.
 4. A computerimplemented problem solving system according to claim 1, and furtherincluding a display screen, said computer generating a screen displayincluding user viewable and modifiable display portions corresponding tosaid set of vocabularies, said at least one knowledge set and saidindividual user preferences.
 5. A computer implemented problem solvingsystem according to claim 1, and further including user accessible meansin said screen display for retrieving net based information for addingto said set of vocabularies, said at least one knowledge set and saidindividual user preferences.
 6. A computer implemented problem solvingsystem according to claim 1, wherein said set of vocabularies, said atleast one knowledge set and said individual user preferences may be usermodified by adding, editing, and deleting elements.
 7. A systemaccording to claim 6, further comprising a program capable of trackingsaid adding, editing, and deleting with user, date, and data valueinformation.
 8. A system according to claim 6, further comprising aprogram for processing user requests to modify using rules governingrelationships among the elements of said set of vocabularies, said atleast one knowledge set and said individual user preferences.
 9. Acomputer implemented problem solving method utilizing an informationstorage infrastructure and a flexible development environment for datastorage, comprising: generating screen displays on a display screen;entering a problem identified by an initial assessment to said computerat a designated place in one of said screen displays; selecting from atleast one of said screen displays at least one item from at least oneof: a stored, user modifiable set of vocabularies related to a problemto be solved, at least one stored, user modifiable knowledge setrelevant to a problem to be solved, and stored, user modifiableindividual user preferences relevant to a problem to be solved, andentering said at least one item to said computer at a designated placein one of said screen displays, applying said knowledge set to diagnoseand manage said problem; naming tools for said problem diagnosis andmanagement using said set of vocabularies; and organizing said problemdiagnosis and management tools using said individual user preferences;wherein said selecting step comprises evaluating said problem to besolved and said generating step comprises providing options to said userto develop a plan to manage said problem to be solved, said methodfurther comprising orienting said user to a status of said problem to besolved by displaying iterations of evaluations and plans related to saidproblem to be solved.
 10. A computer implemented problem solving methodaccording to claim 9, and further including retrieving net basedinformation for adding to said set of vocabularies, said at least oneknowledge set and said individual user preferences.
 11. A computerimplemented problem solving method according to claim 9, and furtherincluding modifying at least one of said set of vocabularies, said atleast one knowledge set and said individual user preferences.
 12. Acomputer implemented problem solving method according to claim 11,wherein said step of modifying comprises at least one of the steps ofadding, editing, and deleting an element.
 13. A computer implementedproblem solving method according to claim 9, wherein said step ofselecting comprises at least one of the steps of retrieving, viewing,adding, and deleting.
 14. A system for creating an electronic medicalrecord using a computer implemented problem solving system having aninformation storage infrastructure and a flexible developmentenvironment for data storage, comprising: a stored, user modifiableprogram including a problem solving rule set relevant to medicaldiagnosis and treatment, a stored, user modifiable set of vocabulariesrelated to medical diagnosis and treatment, at least one stored, usermodifiable knowledge set relevant to medical diagnosis and treatment,and stored, user modifiable individual user preferences relevant tomedical diagnosis and treatment, wherein said knowledge set is appliedto diagnose and treat a problem, said knowledge set nested by bothproblem and stage of diagnosis or treatment; wherein said set ofvocabularies are used to name tools for said diagnosis and treatment;wherein said individual user preferences are used to organize saiddiagnosis and treatment tools; wherein said system allows a user todetermine a medical diagnosis and provides options to said user todevelop a treatment, wherein said system updates said electronic medicalrecord with information concerning said medical diagnosis and saidtreatment; and further wherein said rule set includes iteration ofdiagnoses and treatments, and said system orients said user to a statusof said medical diagnosis and treatment at each iteration to allow saiduser to manage said treatment.
 15. A system according to claim 14, andfurther including: means for generating screen displays on a displayscreen; means for entering a problem identified by an initial assessmentto said computer at a designated place in one of said screen displays;means for selecting from at least one of said screen displays at leastone item from at least one of said stored, user modifiable set ofvocabularies related to medical diagnosis and treatment, said at leastone stored, user modifiable knowledge set relevant to medical diagnosisand treatment, and said stored, user modifiable individual userpreferences relevant to medical diagnosis and treatment, and means forentering said at least one item to said computer at a designated placein one of said screen displays.
 16. A system according to claim 14,wherein said set of vocabularies, said at least one knowledge set andsaid individual user preferences comprise a relational database.
 17. Asolving system according to claim 16, wherein said relational databaseincludes a plurality of tables having a table driven infrastructure. 18.A system according to claim 14, and further including a display screen,said computer generating a screen display including user viewable andmodifiable display portions corresponding to said set of vocabularies,said at least one knowledge set and said individual user preferences.19. A system according to claim 14, and further including useraccessible means in said screen display for retrieving net basedinformation for adding to said set of vocabularies, said at least oneknowledge set and said individual user preferences.
 20. A systemaccording to claim 14, wherein said set of vocabularies, said at leastone knowledge set and said individual user preferences may be usermodified by adding, editing, and deleting elements.
 21. A systemaccording to claim 20, further comprising a program capable of trackingsaid adding, editing, and deleting with user, date, and data valueinformation.
 22. A system according to claim 20, further comprising aprogram for processing user requests to modify using rules governingrelationships among the elements of said set of vocabularies, said atleast one knowledge set and said individual user preferences.
 23. Asystem according to claim 14, further comprising a program forprocessing user requests so that with one click a diagnostic test can beordered and clear instructions are written on how to schedule it and getto the testing facility; in addition, medical necessity is cleared, andany needed prescription is written.
 24. A system according to claim 14,further comprising a program for processing user requests so that uponentering an order, all needed forms and documentation are automaticallygenerated.
 25. A system according to claim 14, further comprising aprogram for creating a screen display including a problem bar,comprising a plurality of individual tabs near the top of the page, andarranged in order of relative importance.
 26. A system according toclaim 25, wherein said tabs are color coded to delineate theimportance/severity of the problems.